The "Childmyths" blog is a spin-off of Jean Mercer's book "Thinking Critically About Child Development: Examining Myths & Misunderstandings"(Sage, 2015; third edition). The blog focuses on parsing mistaken beliefs that can influence people's decisions about childrearing-- for example, beliefs about day care, about punishment, about child psychotherapies, and about adoption.
See also http://thestudyofnonsense.blogspot.com

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Concerned About Unconventional Mental Health Interventions?

Tuesday, January 14, 2014

When care for children without functional families has
been discussed recently, a single perspective has been paramount. This is the
belief that group care in institutions (orphanages) is “toxic” to good
development, and that individualized foster care and adoption are the only
acceptable choices. The proposed Children In Families First (CHIFF) legislation
in the U.S., and the recommendations made by UNICEF about shifting from orphanages
to foster homes, are both based on the claim that scientific evidence strongly
supports the idea that institutional care is in and of itself harmful to
children’s development.

However, the existing evidence is not nearly as strong
as some proponents argue. Today, I want to present some sources of relevant
information, including both older and more recent studies, and to look at their
conclusions and the evidence that supports them.

Historically, it has been fairly common for
children, even infants, to be cared for in groups. Valerie Fildes, in her
fascinating book Wet Nursing, looked
at the practice in France of sending infants to be breastfed in the countryside
for the first two years of their lives. The mothers, who were usually skilled
textile workers, could continue to contribute substantially to the family’s
earnings, while the wet nurse did well for herself and her family by caring for
multiple infants. The mothers might or might not visit their babies, and the
children were badly distressed when suddenly transferred back to their family’s
care and separated from the only caregiver they knew. This does not seem to us
post-Bowlby readers as a very good idea, but in fact (as James Robertson was to
point out much later), when the children were then cared for sympathetically, most
of them did very well. A somewhat similar situation existed in World War II
Britain, when quite young children were evacuated from London to unfamiliar
places and multiple caregivers ( see Churchill’s
Children, by John Welshman), or were cared for in group homes like Anna
Freud’s Hampstead Nurseries. Again, good developmental outcomes were the rule,
rather than a “toxic” effect lasting
through the children’s lifetimes.

No one would claim that wet nursing or evacuation
were interventions that we would expect to be beneficial to development, but
they seem to have done very little harm, and along with ethnographic data
suggest that human beings do not require a single, restricted set of
experiences in order to thrive in early life.

Like other wars, World War II created many orphans,
and institutions for their care were established. Even when the war orphans
were close to adulthood, institutions continued to exist to help unmarried
mothers to deal with pregnancy and to care for children after birth. As these
institutions were in existence contemporaneously with John Bowlby’s formulation
of attachment theory, and because their arrangements were in conflict with Bowlby’s
(now discarded) tenet of monotropy (the need for an infant to form an
attachment to a single caregiver), many questions were asked about the effects
of institutionalization on early development.

One institution that received much early attention
was the Metera, a Greek foundation for unmarried mothers and their babies. According
to a 1960 article in a popular magazine (possibly not very accurate), an infant
born in the Metera was assigned, along
with two other young infants, to two caregivers who lived in the institution,
and who moved along with their three infants to a different ward if a transfer
was made. Family members could visit the children, but the emphasis was on the
relationships with the caregivers; adoptions were to be arranged within a few
months if possible. However, by 1979, practices in the Metera seem to have
changed—or perhaps they were never as positive as previously indicated. Berry
Brazelton and two colleagues examined neonatal behavior of Metera infants, as
compared to other groups (Pediatrics,
63(2)), and found worse performance
on the part of the Metera children at birth. They attributed these difficulties
to the extreme disapproval of unmarried pregnancy in Greece, and the attempts
of the mothers to starve themselves before they arrived at the Metera-- but also mentioned that the infants were in
unstimulating white cubicles and fed on a strict 4-hour schedule. More
recently, Vorria et al (“Early experiences and attachment relationships of
Greek infants raised in residential group care”, Journal of Child Psychology and Psychiatry, 2003, 43 ,pp. 1208-1220) looked at the
development of children who remained in the Metera for many months, and found
that an unusually high number of them showed disorganized attachment (that is,
atypical behavior when a caregiver returns after a separation in a strange
place, for example, freezing in place or backing toward the adult). However,
some showed secure attachment. The children, who had incidentally had much
lower birth weights than a control group, were less advanced cognitively than
home-reared controls. Vorria et al noted that although there were claims that
the Metera babies had plenty of interaction with a small number of caregivers,
in fact they had little interaction in the early months, and were later moved
to a pavilion where the ratio of babies to caregivers was 4-6:1, a situation
where the best-trained and best-motivated caregiver would have difficulty in
being sensitive and responsive to all infant signals.

The interesting point about these studies of the
Metera is that although there was little question that the institutional babies
fared less well than home-reared babies did, the authors did not attribute the
problems to any single factor, particularly not to institutionalization in and
of itself. On the contrary, they looked at characteristics of the infants’ pre-birth
experiences and at specific characteristics of the institution as possible
causes of poor development.

The recent research on which CHIFF and the UNICEF
recommendations depend is the Bucharest Early Intervention Project (BEIP),
conducted by the eminent child psychiatrist Charles Zeanah and many
collaborators, and reported in a growing number of publications. The BEIP
research is unique among investigations of institutional effects on children in that it
involved a randomized controlled trial (RTC), the highest level of research
design, and one which does much to assure that outcomes are caused by the
treatments the children experience, rather than by other unknown factors. As
described by C.H. Zeanah, N.A. Fox, and C.A. Nelson in 2012 (“The Bucharest
Early Intervention Project…”, Journal of
Nervous and Mental Disease, 200, pp. 243-247), this project worked with 136
children 6-31 months old who were being cared for in Romanian orphanages.
Children were assigned at random to remain in the institution where they
already were or to go to a foster home.

BEIP authors have given clear descriptions of the
resources poured into the foster homes. The work included establishment of a
foster care network, as well as training of social workers who would oversee
and encourage the development of relationships between the foster children and
their caregivers. The social workers also received weekly consultations with
expert psychologists in the U.S. It is notable, by the way, that the training
and resources involved here were probably a good deal greater than those
available to foster parents in the U.S. or the U.K.

Publications on the BEIP have given much less detail
about the experiences of the children who were randomized to institutional
care. It would be of much interest to know details of these experiences such as
the ratio of infants to caregivers or the sizes of groups (these factors
generally being considered to have strong effects on the outcomes of day care).
The 2012 article by Zeanah et al references the well-publicized appalling
conditions in Romanian institutions for children following the fall of the
Ceasescu regime in 1989, but does not provide much information about ways in
which orphanages might have changed (for better or worse) in the ensuing
period. This lack of information about the experiences of the children
randomized to the institutional treatment arm makes it difficult to know what
factors actually differed between the two groups, and to what extent they were
different.

An additional difficulty of design has been pointed
out by Douglas Wassenaar, writing in Infant
Mental Health Journal in 2006. Wassenaar noted a problem of scientific
validity in the BEIP study: the fact that evaluators should have been, but were
not, “blinded” to (unaware of) the treatment being received by each child, for “both
the ‘soft’ psychosocial evaluations, which are notoriously subject to rater
bias, and some of the more ‘objective’ physical evaluations”. Wassenaar also
pointed out that this matter should have been discussed by Zeanah and other
BEIP authors, as an important issue with respect to confidence in the
conclusions, “particularly in view of their expressly stated bias favoring
deinstitutionalization”.

In spite of these difficulties and criticisms, BEIP
participants (and many others) have continued to state general conclusions that
the project has shown the advantages of foster care over institutional care for
young children. Fox et al, in the Journal
of Child Psychology and Psychiatry in 2011, stated that children raised in
institutions exhibit lower IQ scores than those raised in family settings.

However, even setting Wassenaar’s concern about
blinding aside, it’s necessary to question what the BEIP data actually show. Is
it not that children who were in high-quality, resource-rich foster care did
better than children who were in institutions whose quality was not clearly
described but may have been abysmal? Is the conclusion not that a particular
group of children, in one set of conditions, did better than another group, in
a specific other set of conditions? Those conclusions are a far cry from saying
that institutions are “toxic”, and that all possible institutional variants are
harmful in comparison to all possible variants of adoption or foster care
(including, perhaps, “mega-families”). The latter statements smell strongly of
the “expressly stated bias favoring deinstitutionalization” mentioned by
Wassenaar and evident in CHIFF and other proposals.

What would have happened if the training and
resources lavished on the foster homes were also provided for the Romanian institutions? That’s the question
that must be answered as a step toward understanding whether institutions are “toxic”
(and I would like to see that sensational “toxicity” metaphor abandoned, as it
distracts from rational discussion). Until we have further information, it will
not be time to say that science supports one view or another of care for children
without parental care. When such statements are made, they should be recognized
as the ideological positions they actually are.

Monday, January 13, 2014

After I commented on some recent discussions of
breastfeeding for adopted children, Karleen Gribble, of the University of
Western Sydney , responded and sent me a copy of her paper “Post
institutionalized adopted children who seek breastfeeding from their new
mothers” (Journal of Pre- and Perinatal
Psychology and Health, 19(3), 217-235). I’m going to comment on Gribble’s
paper today.

Let me say first that I’m thrilled to see more observational
work on care events in infancy and childhood. I consider this to be a
much-neglected topic, and exactly what happens during breastfeeding-- including the many variations-- is rarely given systematic attention. I
attempted to do some data collection of my own some years ago, but
unfortunately La Leche League (it was at one of their functions that I was
observing) was not willing to give permission for this. I also vividly recall being
roundly scolded by the journal editor Marc Bornstein for submitting a comment that
proposed more such work. I confess that I have not been entirely evidence-based
or free from speculation about breastfeeding interaction (www.psychologytoday.com/blog/child-myths/200906/breastfeeding-speculating-wildly),
but this is an area where knowing what to observe depends partly on thinking
through one’s own experiences and other people’s stories. Nonetheless, it’s the
observation rather than the speculation that we need to attain.

In considering Gribble’s paper, it’s important to
look first at the a priori
assumptions it contains. The author refers frequently to breastfeeding as a
causal factor in attachment and attunement, but at the same time concludes the
paper by noting that attachment may need to precede breastfeeding. (It is not
clear whether this implies that newborn infants who breastfeed must already be
attached to their mothers.) In addition to Gribble’s statements in the paper,
we need to look at the reference section and see what authors she considered to
provide appropriate background for her work; these include Deborah Gray, Mary
Hopkins-Best, Terry Levy and Michael Orlans, and Nancy Thomas--- all people
committed to an alternative theory of
attachment rather than to Bowlby’s conventional psychosocial approach. In line
with this background, Gribble references the so-called “attachment cycle” as a
series of experiences that cause emotional attachment (see http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html
for a discussion of this issue). Like other authors who publish in JPPPH, Gribble also references ideas
about children’s memories of birth and early life. All of the assumptions
displayed here suggest that Gribble is very ready to accept the belief that
unconscious, biologically-driven motives and behavior patterns play powerful
roles in children’s development even after the first few months of life have
passed. She quotes a mother as saying that her child’s need to suck was
”primal”, exemplifying the belief I have just described, and suggesting
strongly that some human maternal and child behaviors are best seen as
instinctive.

The assumptions I have just described are in
contradiction to established conventional views of early development (and of
course such conventional views can turn out to be quite wrong, but it has yet
to be shown that they are wrong). Conventionally, feeding modes are not
considered to be important to development of parent-child relationships,
although a parent’s sensitivity and responsiveness to infant feeding cues are
important, just as they are in every other area of parent-child communication. Neither
is skin-to-skin experience thought to play a strong role in establishing
emotional relationships. Infants are not considered to have an attachment to
anyone at the time of birth, nor are they thought to have memories of birth or
of early life. Biologically-determined infant social reactions are thought to
be paramount in the early months, but after that learning from social
interactions begins to take over. While initially biological, modes of
communication become a matter of learning and therefore are strongly culturally
influenced rather than instinctive.

Understanding the assumptions of Gribble’s paper,
and the ways they differ from the foundations of conventional approaches to
early development, let’s go on to look at the information reported about
adopted children wanting to breastfeed. Gribble reports information about 32
adopted children, of both sexes and a range of ages (ages at placement= 8
months to 12 years) and separation histories, whose adoptive mothers stated
that the children asked for breastfeeding or signaled that they wanted to
breastfeed. It is not clear how many of the mothers were actually interviewed
by Gribble, as some of the cases were said to have been reported by social
workers or drawn from published material. In addition, it is unclear what sex
ratio was involved; of the five interviews reported by Gribble, four of the
children were girls.

Gribble’s paper provides an interesting beginning
for discussion of children’s motivation for adoptive nursing, but a much better
context is needed before we can interpret this report. For example, the
Wikipedia article on adoption in Australia states an average of 330
intercountry adoptions per year (the children in Gribble’s study were adopted
from other countries). However, Gribble does not say over how many years her information
was collected, so it is impossible to know whether the 32 children discussed
were a very large or a very small proportion of similar adopted children.

In addition, Gribble does not state or even
speculate upon the number of nonadopted children who, having been bottle-fed
from the beginning, or having been weaned from the breast, later communicate to
their mothers that they want to breastfeed. This is an important issue because
of Gribble’s argument that adoptive breastfeeding facilitates attachment in
children who have experienced separations. Nonadopted children have presumably
had ideal opportunities to develop attachment and have not experienced serious
separations, so if they signal their wish for later nursing in the same proportions
as adopted children, it is hard to see what the emotional motivation for this
behavior would be. A full understanding of the phenomena reported by Gribble awaits information that would permit this
comparison.

Another important unanswered question is the role of
the adoptive mother’s beliefs, expectations, and caregiving behavior in
creating the child’s interest in breastfeeding. Gribble has pointed out
elsewhere that mothers are not likely to provide information about the atypical
behavior of adoptive breastfeeding unless they trust their confidant; this
suggests that the mothers have a belief system that is not entirely shared by
most other people. Gribble states a belief that skin-to-skin contact is
important for attachment, and describes a mother who “used skin-to-skin contact
via co-bathing and a cuddle time in the evening as a way of promoting
attachment”. Mothers who share this belief provide opportunities for breast
contact that would not occur in the Western world in most other situations or
be presented by mothers who did not share the belief. Adoptive mothers who
believe in the “skin-to-skin” and “attachment cycle” system may also accept the
idea that breastfeeding is important for the mother-child relationship and
therefore be exceptionally ready to read child behavior as a wish to nurse.
(Gribble refers to sucking on clothing as such a signal, although mouthing and
sucking objects is common childhood behavior, as often seen in school-age boys
who like to chew on the necks of their t-shirts.) Interestingly, Gribble also describes
children who sought to breastfeed as part of “birth games” played with their
adoptive mothers, suggesting that she is focused on a group of adoptive parents
who are committed to an alternative theory of early development-- not surprising in light of the journal in
which the study was published.

The information Gribble presents is of great
interest, and certainly should be kept in mind in cases where breast-touching
by adopted children is regarded as “sexualized” behavior indicative of previous
sexual abuse. (If Gribble’s reports are accurate, such behavior may not be an
indication of sexual experience at all.) However, interpretation of the
reported cases must await contextualization by information about other adopted
children and about nonadopted children as well. Gribble’s extensive discussion of why adopted
children seek breastfeeding is premature, because we have no idea whether they
actually do so more than nonadopted children do, or whether their adoptive
parents’ belief systems lead them to read child messages differently than they
might otherwise do.

As a final comment, I want to turn to two sentences
that Gribble places at the end of the article abstract and that she does not
actually discuss in the body of the paper. The first sentence states that the “frequency
of adopted children seeking breastfeeding is unknown, however adoption
professionals should advise adoption applicants of the possibility”. Such
advice, if it is being given, is certainly likely to increase the number of
cases where mothers interpret ambiguous behavior as bids for breastfeeding.

In a second sentence at the end of the abstract,
Gribble makes the following claim: “It may also be appropriate for adoptive
mothers to pursue breastfeeding in the event that the child does not.” Nothing
in the paper provides grounds for this claim, and it is most concerning to
think that a group of parents who have already (as Gribble notes) experienced
various disappointments and losses should be offered an additional challenge
when there is no evidence that it is necessary.

About Me https://en.wikipedia.org/wiki/Jean_Mercer

Jean Mercer has a Ph.D in Psychology from Brandeis University, earned when that institution was 20 years old (you do the math). She is Professor Emerita of Psychology at Richard Stockton College, where for many years she taught developmental psychology, research methods, perception, and history of psychology. Since about 2000 her focus has been on potentially dangerous child psychotherapies, and she has published several related books and a number of articles in professional journals.
Her CV can be seen at http://childmyths.blogspot.com/2009/12/curriculum-vitae-jean.mercer-richard.html.